呼吸机使用指征

呼吸机使用指征 呼吸机使用指征、适应证及非适应证 (一)使用指征 可以从呼吸功能，氧交换，与肺通气三因素来考虑。凡是通气不足和(或)氧合欠佳，面罩给氧后以下各项常用参数达不到3,1中所示值者，均需要机械通气，呼吸支持，这也是心肺复苏后病人应首选的治疗手段。 表3,1 人工呼吸机使用指征 项目 需要机械通气值 正常值 呼吸功能: 呼吸频率(RR)次/min ,30,35或,5 10,20 1,5或,正常值 潮气量(VT)mL/kg 6,15 3 60,80 肺活量(VC)mL/kg ,15 75,100 最大吸气负压(MIF)cmHO ,25 2 氧交换功能: 80,100 动脉血氧分压(PaO)mmHg ,60 2 通气功能: 35,45 动脉二氧化碳分压(PaCO)mmHg ,60 2 0.3 死腔指数(VD/VT) ,0.6 (二)适应证 1、外科疾病及手术后呼吸支持。?严重胸部、肺部外伤、多发性肋骨骨折和链枷胸、颅脑、腹部及四肢严重多发性创作而引起的呼for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 吸功能不全者。?体外循环下心内直视手术后行短期(一般术后6,48小时或数天或更长)机械通气，可改善氧合，减少呼吸作功，降低肺血管阻力，以利心功能恢复。?一侧全肺切除及上腹部手术后引起呼吸功能不全。?各类创伤、休克、严重感染(如急性重症胰腺炎)、大量输血引起的急性呼吸窘迫综合征(ARDS)。?重症肌无力施行胸腺手术后发生呼吸困难和缺氧等肌无力危象。 2、气体交换障碍。?急性呼吸窘迫综合征(ARDS)或急性肺损伤。?新生儿透明膜病(IHMD)。?心力衰竭、肺水肿、肺动脉高压及右向左分流病人。?慢性肺部疾病如哮喘和慢性阻塞性肺气肿(COPD)并感染出现急性呼吸衰竭或低氧血症时。?严重急性肺部感染出现呼吸衰竭时。 3、呼吸机械活动障碍。?神经肌肉疾病(如格林巴利综合征)。?中枢神经功能障碍(如吗啡、巴比妥类药物过量、抑制呼吸中枢)。?骨骼肌病变及脊柱和胸部畸形等。 4、麻醉和手术中的呼吸支持。麻醉术中应用机械通气不仅可代替人工手法呼吸，而且可进行治疗。如颅脑手术中可使用过度通气、排出二氧化碳，刺激脑血管收缩，减轻脑水肿，从而降低颅内压，达到治疗目的;心脏手术术中呼吸支持，既可支持呼吸又能改善循环功能。 5、心肺复苏后呼吸支持。 (三)非适应证 1、未引流的气胸。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 2、肺大泡。 3、肺气肿。 4、支气管胸膜瘘。 5、低血压(在血容量未纠正之前)。 6、急性心肌梗死及大咯血。 随着机械通气技术的发展，使用呼吸机的禁忌证已越来越少，上述非适应证均为相对禁忌，目前公认的禁忌证主要有严重的急性心肌梗死与大咯血，但也非绝对禁忌证。 当左心急性心肌梗死而有左心衰竭及肺水肿者，仍需要机械通气。对于大咯血病人，有时需要气管内插管，以保持气管通畅，并及时吸除阻塞气管的血液或血凝块，在间歇期间亦可行辅助呼吸。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 常用呼吸模式(MODE)或通气方式的选择 使用呼吸机的任何一种通气方式均应考虑如下一些安全条件:?正压通气对血流动力学的生理影响。?机械通气所引起的肺损伤(或称肺气压伤)。?尽可能保持通气/血流的正常比值。?尽可能保留自主呼吸，同时不增加呼吸作功。因此各类医护人员，尤其是临床医师应很好地掌握各类通气模式的意义、原理、重要作用、适应证、使用及其优缺点，才能在临床上进行正确选择，达到有效的治疗目的。 (一)机械控制通气 机械控制通气(CMV)是与自主呼吸完全相反的一种被动通气方式，潮气量和呼吸频率完全由呼吸机产生，与病人的呼吸周期无关，可用于麻醉中或无自主呼吸的病人，因此，在病人无自主呼吸时，CMV是最基本、最常用的支持通气的方式。CMV包括容量控制(VCV)和压力控制通气(PCV)。间歇正压通气(IPPV)是CMV中最常用的方式之一。使用此方式时，不管病人自主呼吸情况如何，呼吸机均按预调的通气参数，为病人进行间歇正压通气。在IPPV时吸气由呼吸机产生正压、将气流送入肺内，呼吸道内压升高，呼气时肺内气体靠胸、肺弹性回缩、排出气体、IPPV可改善病人的通气和氧合，促使CO排出、提高PaO以维持正常的呼吸功能。适应于呼22 吸停止，通气不足和呼吸功能不全者，尤其适用于神经肌肉疾病引起的呼吸停止，麻醉和手术过程中应用肌肉松弛药后作控制呼吸，以及血容量过多的心力衰竭病人的呼吸支持，可减少静脉回心血量。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet (二)机械辅助通气(AMV) 呼吸机具有触发灵敏度装置(即吸气敏感度)，当病人存在微弱的自主呼吸时，吸气时气道内压降至零或负压，可触发呼吸机作功，从而引发呼吸机同步送气进行辅助呼吸。呼气时，呼吸机停止工作，肺内气体靠胸肺的弹性回缩排出体外。AMV具有以下优点:?保持病人吸与呼吸机工作同步配合，以利于撤离呼吸机。?可使因中枢抑制引起的呼吸功能不全更易恢复。其缺点为:?当病人吸气用力强弱不等时，传感器装置的灵敏度调节比较困难，易发生通气不足和过度换气。?由于机械装置和管道较长的原因，病人开始吸气时，呼吸机要滞后20毫秒左右才能送气、呼吸频率越快，呼吸机滞后的时间相对越长。因此病人呼吸频率越快时，AMV通气效果欠佳。 (三)辅助/控制通气(A/C) A/C模式是将AMV与CMV的特点结合应用，当病人存在自主呼吸并能触发呼吸机送气时为AMV，其通气频率由病人自主呼吸决定。当病人无自主呼吸或吸气负压达不到预设触发灵敏度时，机器可自动转换为CMV，并按照预设的呼吸频率和潮气量送气，因此预设频率作为备用频率，当病人自主呼吸频率不够时，呼吸机即以备用频率取代并送入预定潮气量。A/C模式是目前临床上最常用的气支持方式之一。 (四)压力支持通气(PSV) PSV是一种部分支持通气方式，在病人有一定程度的自主呼吸(通常是呼吸频率够而潮气量不够)的情况下使用。病人吸气时，呼for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 吸机提供预定的正压，以帮助病人克服气道阻力和扩张肺脏、减少吸气用力，并增加潮气量。吸气末气道正压消失，允许病人无妨碍呼气。如果选择压力支持水平恰当，病人能得到需要的呼吸辅助，并能自由决定呼吸频率。PSV是一种较新的通气方式，与AMV不同之处是当病人吸气触发呼吸机送气时，呼吸机所给予的是一恒定送压力，而吸气流速方式、呼吸深度和吸气时间都由病人自主决定。随着病人病情好转和呼吸肌疲劳的清除、应及时降低压力支持水平，以便让病人呼吸肌得到锻炼。PSV仅适合呼吸中枢驱动的兴奋性正常或偏高(即自主呼吸频率正常或偏快)的病人，对于严重中枢性呼吸抑制或麻痹的病人，应避免使用PSV方式。 (五)间歇指令通气(IMV)和同步间歇指令通气(SIMV) IMV指病人在自主呼吸的同时，间断给予CMV，是自发呼吸与控制呼吸的结合，在自主呼吸基础上，给病人有规律的间歇的指令通气，将气体强制送入肺内，提供病人所需要的部分通气量，由于CMV与自主呼吸不同步时可能出现人机对抗，故IMV已不常用。SIMV是IMV的一种改良方式，其优点是保证了机械通气与病人自主呼吸同步，又不干扰病人的自主呼吸，使用SIMV时除调节通气频率外，还需调节呼吸机的触发灵敏度，通过吸气努力，使指令通气与自主呼吸同步。IMV或SIMV已成为撤离呼吸机前的必要通气方式。 (六)分钟指令通气(MMV) 呼吸机内装有微处理器管理呼吸功能的一种通气方式，为一个每分钟通气量恒定的系统，能保证病人每分钟呼吸一定容量(自主或强for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 制)。在病人自主呼吸减弱或停止时，呼吸机能自动补偿通气量并报警。MMV避免了IMV、SIMV的缺点，无需操作者调节呼吸机，同时不干扰病人的自主呼吸，更易从机械通气过渡到自主呼吸，因此 ，常用于呼吸运动不稳定和通气量有变化的病人，应用于撤离呼吸机则更安全。 (七)呼气末正压(PEEP)和持续气管正压通气(CPAP) PEEP是指吸气由病人自主呼吸触发或呼吸机产生，而呼气末借助于装在呼气端的限制气流活瓣装置，使气道压力高于大气压，从而在呼气末维持呼吸道一定正压的呼吸方式。PEEP可增加呼气末肺容量，使萎陷的肺泡重新扩张，肺膨胀，功能残气量增加，氧合增加，同时呼气末正压可使小气道开放，利于二氧化碳排出。因此，可减少肺不张，改善缺氧，是治疗低氧血症的重要手段之一。但PEEP可增加胸内压，影响心血管功能，主要是回心血量减少，心输出量降低，血压降低。特别是在血容量不足或使用高PEEP值时，此作用更明显，因此，临床应用时需选择最佳的PEEP压力，达到既改善通气，改善氧合，提高氧分压，而又对循环功能影响最小或无影响。一般来说，当机械通气模式和参数选择恰当，当FiO达50%或以上，PaO仍小22于60mmHg时，可适当加用PEEP、且PEEP从490Pa(5cmHO)开2始，根据氧合改善情况和血流动力学监测结果逐步升高，最高以不超过1471Pa(15cmHO)为宜。 2 CPAP是在病人自主呼吸状态下，于吸气期和呼气期均由呼吸机向气道内输送一个恒定的新鲜正压气流，正压气流大于吸气气流，气for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 道内保持持续正气，气流量和正压可按病人情况调节，吸气期恒定的正压气流、可使潮气量增加，吸气省力，从而减少吸气作功，病人自觉舒服;呼气期持续气道内正压，可起到PEEP作用，有助于防止肺萎缩，改善肺顺应性，增加功能残气量，治疗ARDS，哮喘及解除支气管痉挛等，同时在撤离呼吸机前，病人自主呼吸恢复良好，可使用CPAP、196,490Pa(2,5cmHO)，对降低 FiO和提高PaO是十分222可取和非常有效的。 PEEP和CPAP之区别为:?产生方式不同，PEEP为呼气末由呼吸机输给一个正压气流，而CPAP则在吸气与呼气末均由机器输送持续正压气流。?使用对象不同，PEEP是机械通气时使用，而CPAP则在病人有自主呼吸时使用。?对生理影响不同， PEEP增加呼吸肌作功，而CPAP可减少吸气用力，减少呼吸肌作功。?对循环的影响不同，PEEP对循环的影响大，而CPAP对循环的影响小。?增加功能残气量的水平不同，PEEP功能残气量增加较少，而CPAP增加则较多。 (八)自主呼吸 病人自主呼吸恢复较好时，呼吸机辅助病人增加新鲜气流，减少呼吸作功，自主呼吸方式常由CPAP和PSV组成，CPAP和PSV都是由于病人的自主呼吸达到触发水平后工作的，能够辅助病人的部分呼吸作功。 (九)深吸气 深吸气即每间隔一段时间或一定的呼吸次数通气后、呼吸机送入for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 一次相当于1.5,2倍潮气量的气量，自动强加一次深吸气，其生理功能为定期使肺泡过度扩张，可预防长期IPPV时肺泡凹陷不张，可防止肺萎缩。Sigh在现代多功能呼吸机均有可预设装置。 (十)反比通气 反比通气(IRV)即吸:呼(I:E)比值与正常的I:E比值截然相反，吸气时间,呼气时间。I:E可在1:1,4:1的范围内调节。反比通气由于吸气时间延长，其机制类似PEEP，能改善氧合，增加二氧化碳排出，增加肺功能残气量，可防止肺泡萎缩。但IRV可使平均气道压力增高，心排血量减少和肺气压伤机会增多，因此一般只限于自主呼吸消失的病人使用，即一般只有VCV，PCV两种形式才能进行IRV。 (十一)双水平气道正压通气(Bi,PAP) Bi,PAP是一种适合于病人整个机械通气时期的方式，是一种时间启动、压力限定、时间切换的方式。在通气周期的任何时间均可进行不受限制的自主呼吸、Bi,PAP是一种无创性通气方式，是在CPAP的基础上加上PSV。Bi,PAP的优点是经面罩进行通气支持，不需要建立人工气道，也不影响病人的语言、活动和饮食，因而较舒适，病人容易接受，可用于家庭、可不备高压氧气源，适合于早期呼吸功能不全和阻塞性睡眠呼吸暂停综合征等。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 呼吸机的操作管理及观察 1、根据病情需要选择合适的呼吸机，一般选用性能良好、功能较全的机型，要求操作人员了解上机指证与适应证，熟悉各类呼吸机的性能并掌握常规操作方法。如小儿或婴幼儿，宜选用具有小儿呼吸参数设置功能和小儿管道的呼吸机。 2、湿化器、储水罐中置入过滤纸及无菌蒸馏水(或用冷开水)至上下限之间，注意勿加入生理盐水，以免氯化钠结晶析出，沉积粘附于气管、支气管壁上，影响气管、支气管粘膜上皮细胞纤毛运动，不利于痰液排出。 3、检查气源压力，电源电压是否合要求，如电源电压与呼吸机相匹配，氧气压力及压缩空气符合呼吸机工作压力要求，则连接呼吸回路，接摸拟肺，接通气路与电路，开机进行试机。开机步骤为:先开启空气压缩机，再开主机开关，最后根据情况开启加温湿化器开关。必要时，若病情需要进行雾化用药，可开启雾化装置。 4、备齐所需用物至病人床旁，核对床号、姓名无误后，对清醒病人给予解释，说明目的，并交待上机后注意事项，争取配合。对昏迷、躁动病人予适当镇静和必要的约束，以防意外拔管。 5、启动呼吸机后，根据病人的病情和体重、年龄与性别等预设潮气量，呼吸频率，吸氧浓度和呼吸比等参数，并设置通气模式。 6、上机后，严密监测呼吸与循环各项指标，并认真做好记录，包括病人心率、血压、血氧饱和度(SaO)、呼吸频率、潮气量等，2 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 观察病人全身一般情况，尤其是面色、肢温、呼吸节律、胸廓运动状况等。上机30min后，抽动脉血气分析，查低氧有否改善，并根据血气结果调节参数。 7、加强湿化和雾化:机械通气时吸入气体必须经过加温湿化。现代呼吸机均有较为完善的湿化装置，其功能有着“人工鼻”的作用，常见的湿化、雾化方式有:?加温湿化，即用电热丝对电容器内水进行加温，可增加吸入气体的温度和湿度，加温湿化器可进行调节，一 0般控制吸入气体的温度为28,32C，相对湿度,过70%，以免呼吸道中痰液干燥、结痂、阻塞呼吸道。?气道内滴药，用人工的方法向气道内持续或间断滴入生理盐水(必要时可加入α,糜蛋白酶，地塞米松及敏感的抗生素)，有湿化痰液，抗炎等作用。一般病人，只用生理盐水以1,2mL/h间断滴入气道，便可达到湿化目的。?气管灌洗或称呼吸道清扫，其方法为:每次经气管插管或气管切开导管处注入10,20mL生理盐水，保留15秒后，吸出。如此反复2,3次，将肺内污液洗出。主要适应于有误吸、窒息、吸入性肺炎等病人。如溺水或外伤后呕吐误吸等病人。?雾化吸入包括超声雾化和呼吸机压缩机雾化。超声雾化是利用超声雾化发生器或超声雾化机，将生理盐水及药物(依病情加入适当的药物，包括糜蛋白酶，激素及敏感的抗生素等)雾化成0.5,1μm直径的雾滴、有较高的穿透性，能随病人呼吸吸入，达到终末细支气管和肺泡，因而达到湿化和药物治疗的目的。利用超声雾化机雾化一般适应于有自主呼吸，且能短时脱机的病人。呼吸机雾化则是在呼吸机吸气管路上增设雾化杯，其内加入配有所需for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 药物的雾化液，连接呼吸机雾化装置，开启呼吸机雾化钮，利用高速气流将药滴分子打散成2,3μm直径的颗粒，随吸气动作雾粒被吸入下呼吸道和肺泡，起到治疗作用。总之，湿化和雾化是进行机械通气的必备条件之一。 8、气管内勤滴药、勤翻身、勤拍背、勤吸痰，保持呼吸道通畅。行机械通气的病人，应1,2小时翻身拍背1次，促使痰液松动，以利咳出或吸出，1,2小时向气管导管内滴入2,5mL生理盐水以稀释痰液，易于吸出。每隔1,2小时吸痰，清理呼吸道1次，对有梗阻的病人气管，可用纤维支气管镜清除梗阻物如痰液、血块等，吸痰时应注意:?根据气管插管长度及内径选择长短、粗细适宜的吸痰管，管质有硅胶导管与橡胶吸痰管，有一般吸痰管和带侧孔的减压吸痰管，应酌情选用。?吸痰前、后适当调高输氧浓度减少缺氧。?吸痰时，严密观察病情变化，如面色、生命体征、动脉血氧饱和度等。?每次吸痰时间不宜过长，一般12秒。?先吸气道再吸口、鼻腔分泌物。?吸痰管一用一消毒。目前，气管切开导管常采用一次性硅胶导管，管腔粗，但无内套管，分泌物易于沉积粘附其内壁上，如不及时清理，极易干结阻塞呼吸道，保持气道通畅是十分必要的。 9、严格遵守无菌操作规程，预防机械通气所致呼吸道感染。由于气管插管或气管切开等人工气道的建立，使上呼吸道滤过器失去作用，气管、支气管的纤毛活动减退或消失，破坏了肺免受感染的保护机制，若气管湿化不足，分泌物干结，未及时吸出，引流不畅;或吸痰管、呼吸机和湿化器消毒不严;或操作不人为污染器械工具;for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 或病人营养不良及机体抵抗力低下等因素均可成为造成呼吸道感染的主要原因。因此，护理机械通气的病人应注意以下几点:?严格消毒呼吸治疗器械及其管道，能高压灭菌的物品，一般采取高压灭菌处理。?严格无菌吸痰法，先吸气管内分泌物，再吸口鼻腔分泌物，吸痰管一用一消毒。?持续机械通气者，应2,4小时，放松气囊1次，以免气道局部长期受压，缺血、坏死，每次放松时间为10,15分钟，注意放松气囊前应先吸尽病人口腔分泌物，以防病人误吸。?气管插管病人口腔护理2,3次/d。气管切开病人，每班按气管切开护理常规执行。?定期更换呼吸管道(24,48小时)，及时清除管道中冷凝水，防止误吸。?因湿化可使支气管粘膜纤毛运动活跃，稀释分泌物。因此，定期气道内滴药、雾化、吸痰、清理呼吸道显得尤为重要。?昏迷病人每1,2小时翻身，拍背1次，预防肺部感染和皮肤并发症发生(主要是压疮)。清醒病人鼓励咳嗽排痰，如因伤口疼痛可行镇痛后进行，或由护士协助按压伤口，鼓励病人有效排痰。?正确采集痰培养标本，协助诊断与治疗。 10、昏迷躁动病人应适当给予镇静剂，约束四肢以防导管移位，或病人意外拔管。清醒病人应加强心理护理，勤观察，多问候，多安慰、解释，消除或减少紧张恐惧心理。 11、发现人—机对抗应及时查原因并处理。人—机对抗即呼吸机送气时，病人屏气或呼气，从而发生呼吸不同步或出现呼吸对抗，影响通气效果。常见人—机对抗原因有:?病人不习惯。?呼吸机轻微漏气或压力调节太高。?通气量不足。?严重缺氧。?疼痛。?存在for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 其他引起用力呼吸的因素，如气胸、心力衰竭等。?气管内有痰液集聚。?呼吸参数和通气模式选择不当。出现人—机对抗的处理措施:?寻找引起呼吸不同步的原因，并逐项纠正。?若为通气不足，可试用简易人工呼吸器作人工过度通气，以减弱或打断自主呼吸，然后再进行常规机械通气。?仔细检查气管插管位置，有无分泌物滞留和气囊是否漏气，以排除机械因素而致不同步。?适当调整通气模式和呼吸参数。?适当使用镇静剂，如地西泮、吗啡、芬太尼等药，必要时可用肌松剂来消除自主呼吸。但值得注意的是镇静剂和肌松剂使用前，一定要排除其他人—机对抗因素后，才慎用。 12、人工呼吸机的放置应与病人保持一定距离，以免病人自己触摸或转动调节旋钮而出现意外。 13、重视呼吸机报警信号，发现报警，应及时查原因并处理，尤其是对突发呼吸机故障如停电，或病人发气胸，呼吸困难等情况，应有清醒的认识和处理能力。呼吸机常用的报警显示有声控报警与光控报警，大部分现代呼吸机可声、光兼控报警。护士应注意根据报警声音区分是恶性报警(常常有刺耳尖叫声)还是一般性质的报警(报警声较柔和)。 常见报警参数及异常原因:?工作压力报警，可有高压报警，其主要原因为限制气道压力上升而超出安全范围。低压报警的原因有:气源压力不足;潮气量过大，吸气时间过短;进气阀故障;气道管路漏气;工作压力未设置等。?容量报警或分钟通气量报警，过高原因为:高限值设定过低;呼吸频率过快。过低原因为:低限值设定过高;for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 气囊或管路部分漏气等。?气道阻力过高报警:气道梗阻如痰痂，分泌物阻塞，病人支气管痉挛，气管套管脱出等;呼吸系统弹性降低，包括肌张力增高、主支气管阻塞、气胸等。?呼吸机工作状态突然停止的原因有:突然停电或电源插头松脱，而呼吸机本身无蓄电池代偿时;呼吸机机器本身出现故障，使得自检不通过，不作功等。因此护士在操作管理呼吸机时，一定要重视报警信号，分析、查明报警原因，及时纠正异常，或医生，协助处理报警，同时应结合临床观察，不要过分依赖呼吸机报警装置，以免报警失灵时出现意外。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 机械通气常见并发症及原因 (一)气管插管、气管套管产生的并发症 1、导管进入支气管，原因常为插管过深或导管固定不牢产生移位，而致一侧肺不张。 2、导管或套管阻塞，主要为分泌物多而稠，清理不及时，不彻底引起。 3、气管粘膜出血、坏死，主要为套囊充气过度，压力过高，或金属管的局部压迫。 4、导管脱出或自动拔管，主要原因为躁动病人约束不力，导管固定不牢等，可造成气道急性梗阻而窒息，必须立即准备重新插管。 (二)呼吸机故障引起的并发症 1、漏气，达不到顶置潮气量，呼吸机出现低峰值压、代容量报警，病人胸廓活动幅度减少。主要原因为气管导管套囊漏气或破裂，呼吸机管道系统有破口等，若原因一时不能找出或排除，则应用手控呼吸或更换呼吸机。 2、接管脱落或管道接错，均可造成机械通气完全停止或呼吸道阻塞而危及病人生命。 3、气源或电源突然中断，呼吸机报警装置失灵，表现为呼吸机突然停止工作，产生刺耳样尖叫声，提示医务人员检查供氧及电源等装置，及时解除报警。若病人通气良好时，呼吸机发生报警声，或病人通气不足时，呼吸机报警器又不响，则提示报警装置失灵，应停机for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 检修，否则可能危及病人生命。 (三)长期进行机械通气而产生的并发症 1、通气不足，最常见的原因是呼吸道内分泌物积滞、管道系统漏气或使用镇静剂量，麻醉剂和肌肉松弛剂不当抑制了自主呼吸，也可由于设定参数不够或未做及时调整而引起，使得潮气量与通气频率均不够而引起呼吸性酸中毒及低氧血症等表现。因此要认真查找原因，进行对症处理。 2、通气过度，由于呼吸频率或潮气量太大，使得CO过度排出，2产生低碳酸血症，呼吸性碱中毒，病人可出现心律失常，血钾降低，氧离解曲线左移，结合氧不能释放，从而加重组织缺氧。预防措施为:?适当调节通气频率和潮气量。?应用SIMV模式辅助通气。?应用适量镇静剂，降低自主呼吸频率。?必要时还可延长呼吸机Y形管与人工气道间的管道以加大气道无效腔，并增加重复吸收气量，从而减少CO排出，维持适应的PaCO值在6.0,7.3kPa(45,55mmHg)。 22 3、心排出量下降和低血压，机械通气常使用正压，PEEP和CPAP又进一步使胸内压增加，阻碍了外周静脉回流，使回心血量减少，血容量不足使得心脏代偿功能减退，肺泡压升高，使得肺血管床受压，肺循环阻力增加，心排血量减少，从而致病人血压降低。预防措施为:?根据病情选择最佳PEEP值，既改善了通气，又不影响循环。?适当补充血容量，使静脉回流量增加，心排血量可恢复正常。?增加正性肌力药物的应用，可提高心肌收缩力，提高病人心排血量，增加全身氧输送，有利于防止机械通气病人的循环功能改变。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 4、肺气压伤，其直接原因为吸气压峰值增高。表现为气胸、纵隔气肿，肺间质水肿、积气、皮下气肿及气腹等。病人常躁动不安、心率增快、血压下降、患侧胸部叩诊为鼓音，呼吸音降低或消失，皮下气肿可听到捻发音。预防措施为:?正确调节气道压与潮气量值，勿使过高、过大，尤其是有慢性肺部疾患的病人。?加强生命体征监测，常听双侧呼吸音。?气胸时应立即进行减压引流。 5、氧中毒与呼吸机肺，主要原因为长时间、持续高浓度氧，引起氧中毒，可使肺泡组织广泛水肿、渗出、甚至发生纤维样改变，降低肺弹性，产生肺损害，长期使用呼吸机而产生致死性肺损害即为呼吸机肺。它是机械通气最为严重的并发症，它的产生往往与肺气压伤和氧中毒有关，因此应予以重视。对于长期依赖机械通气的病人应尽可能避免使用高压力、高氧浓度的给氧。 6、呼吸道感染，常见原因:?人工气道的建立，如气管插管或气管切开为感染的门户。?呼吸道自然防御保护机制减弱，如气道过滤器失去作用，纤毛活动减退。?气道加温、湿化作用降低，痰液等分泌物易聚积，阻塞气道。?医源性操作不规范，各类管道、湿化器消毒不严，为感染的主要原因。?病人原有疾病，营养不良，机体抵抗力低下等。具体预防措施详见ICU医院内感染监控章节。 7、其他器官的并发症: (1)胃肠道并发症，有胃肠道胀气，胃肠道出血等，胃肠充气膨胀的原因常为气管套管套囊充气不足，正压通气的气体可以从气囊旁经口鼻外逸，刺激咽喉部引起吞咽反射，导致气体被吞入胃内引起for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 胀气。另外过度通气所致的呼吸性碱中毒和低钾血症亦为胃肠胀气的一种原因。胃肠道出血常见的原因则是应激性溃疡所致。胃肠胀气可置胃肠减压管或置肛管持续排气，亦可进行腹部热敷，促进肠蠕动。上消化道大出血可用H受体阻滞剂(如雷尼替丁)或胃酸泵抑制剂2 (洛赛克)制酸，凝血酶或其他止血剂口服，或用去甲肾上腺素冰盐 0水(4C)胃腔灌洗止血。密切观察生命体征改变及大便性质。 (2)肝功能受损，主要原因为机械通气所致肝静脉、门静脉压力增高，肝淤血和淤胆的改变，一般不需特殊处理。只需定期监测肝功能情况。 (3)肾功能损害，表现为水肿和少尿，机械通气可导致肾淤血等一系列改变，产生水钠潴留、少尿及全身水肿等症，故机械通气病人应常规监测尿量、尿密度及肾功能的变化，在保证足够血容量的情况下，可适当应用利尿剂(呋塞米)和扩张肾动脉的药物(多巴胺)，以促进排尿，减轻水肿。对于皮肤高度水肿的病人，应加强皮肤护理，避免皮肤并发症的发生。若阴囊等组织疏松的部位高度水肿，应用多头带托起，垫高以增加局部血流。若四肢严重水肿亦应抬高四肢，并鼓励适当活动，以改善局部血运，减少深静脉栓塞。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet